Emotional and Cognitive Impact of Virtual Patient Simulation on Medical Students in The GCC: A Mixed-Methods Study
About this article
Keywords:
Virtual Patient Simulation; Stress; Confidence; Clinical Decision-Making; Medical Education; Mixed Methods; Grounded Theory; GCCAbstract
This study investigates the emotional and cognitive transformations of medical students engaged in Body Interact Virtual Patient Simulation (VPS) at Arabian Gulf University, Bahrain. This study utilizes a mixed-methods approach comprising pre/post surveys (N=35), tutor observations, and audio transcript analysis to investigate the progression from initial stress and diagnostic uncertainty to improved confidence and clinical assurance. Quantitative results demonstrated statistically significant improvements in flow (Q12: p = 0.0069, d = 0.69) and moderate enhancements in enjoyment and perceived absorption (Table 4.1). Emotional peaks, particularly fear and hesitation during Session 2, were documented through NRC sentiment analysis (Figure 4.4) and thematic audio coding (Table 4.6), while confidence steadily increased across Sessions 4 and 5.
A novel theoretical framework, the Dual-Phase Stress Adaptation Theory, was established through grounded theory analysis (Figure 4.5), clarifying the phased transition from stress to confidence through scaffolded repetition and social feedback. The model was quantitatively supported by OSCE performance correlations (r = 0.73, Table 4.11) and effect sizes associated with clinical decision-making (d = 1.33). A predictive performance model delineates the trajectory of learning: Performance = 0.71(Tolerance) − 0.33(Acute Stress) + 0.40(Team Sup-port) − 0.15(Technical Issues) (Equation 6.9, p. 250).
The findings validate VPS as a cognitive enhancer and emotional support system in medical education, particularly in GCC contexts where data on VPS is scarce. The results of this investigation demonstrate that structured simulation can improve diagnostic reasoning, enhance confidence, and alleviate tension when implemented according to psychologically responsive design principles.
References
Fayzeh Jaber, Nour Jaber, Asif Mahmood, and Ayman Al-Khazraji, “Enhancing medical students’ skill development: the role of virtual patient sim-ulation tools,” IET Conference Proceedings, Mar. 2025. https://doi.org/10.1049/icp.2025.0864.
F. A. Jaber and A. Al-Khazraji, “Integrating augmented reality technology in higher education,” in 7th IET Smart Cities Symposium (SCS 2023), Institution of Engineering and Technology, 2023, pp. 217–228. https://doi.org/10.1049/icp.2024.0928.
M. A. Musen, B. Middleton, and R. A. Greenes, “Clinical Decision-Support Systems,” in Biomedical Informatics, Cham: Springer International Publishing, 2021, pp. 795–840. https://doi.org/10.1007/978-3-030-58721-5_24.
L. A. Shay and J. E. Lafata, “Where Is the Evidence? A Systematic Review of Shared Decision Making and Patient Outcomes,” Medical Decision Making, vol. 35, no. 1, pp. 114–131, Jan. 2015, https://doi.org/10.1177/0272989X14551638.
A. A. Kononowicz et al., “Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration.,” J Med Internet Res, vol. 21, no. 7, p. e14676, Jul. 2019, https://doi.org/10.2196/14676.
View more references (54)
A. Dunin-Borkowska, A. M. C. Pinto, J. Xu, N. Bhandari, and L. Ranasinghe, “Evaluating the Utility of a Near-Peer Situation-Based Course to Prepare Medical Students for the UK Foundation Programme: A Pilot Study,” Adv Med Educ Pract, vol. 14, no. November, pp. 1317–1325, 2023, https://doi.org/10.2147/AMEP.S434080.
P. Croskerry and G. Norman, “Overconfidence in Clinical Decision Making,” Am J Med, vol. 121, no. 5, pp. S24–S29, May 2008, https://doi.org/10.1016/j.amjmed.2008.02.001.
E. P. Monico, “Patient Safety in Emergency Medicine,” Ann Emerg Med, vol. 54, no. 4, p. 644, Oct. 2009, https://doi.org/10.1016/j.annemergmed.2009.04.001.
D. A. ALQahtani, J. I. Rotgans, N. E. Ahmed, I. A. Alalwan, and M. E. M. Magzoub, “The Influence of Time Pressure and Case Complexity on Physicians׳ Diagnostic Performance,” Health Professions Education, vol. 2, no. 2, pp. 99–105, Dec. 2016, https://doi.org/10.1016/j.hpe.2016.01.006.
S. Corrao and C. Argano, “Rethinking clinical decision-making to improve clinical reasoning,” Front Med (Lausanne), vol. 9, Sep. 2022, https://doi.org/10.3389/fmed.2022.900543.
G. García-Castro and F. J. Ruiz-Ortega, “Clinical reasoning and medical education: Scoping Review,” Educación Médica, vol. 22, no. 2, pp. 106–110, Mar. 2021, https://doi.org/10.1016/j.edumed.2020.11.015.
R. M. Jendyk, “Decision Making in Different Care Settings: Do Undergraduate Students Already Care?,” Health Professions Education, vol. 2, no. 2, pp. 114–120, Dec. 2016, https://doi.org/10.1016/j.hpe.2016.01.008.
D. Khullar, A. K. Jha, and A. B. Jena, “Reducing Diagnostic Errors — Why Now?,” New England Journal of Medicine, vol. 373, no. 26, pp. 2491–2493, Dec. 2015, https://doi.org/10.1056/NEJMp1508044.
K. Macauley, “Evaluating Changes in Clinical Decision-Making in Physical Therapy Students After Participating in Simulation,” Health Professions Education, vol. 4, no. 4, pp. 278–286, Dec. 2018, https://doi.org/10.1016/j.hpe.2018.06.001.
S. D. Monteiro, J. Sherbino, A. Patel, I. Mazzetti, G. R. Norman, and E. Howey, “Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough,” J Gen Intern Med, vol. 30, no. 9, pp. 1270–1274, Sep. 2015, https://doi.org/10.1007/s11606-015-3369-4.
T. Swanwick, “Understanding Medical Education,” in Understanding Medical Education, Wiley, 2018, pp. 1–6. https://doi.org/10.1002/9781119373780.ch1.
P. F. Wimmers and G. F. Schauer, “Validating OSCE Performance: The Impact of General Intelligence,” Health Professions Education, vol. 3, no. 2, pp. 79–84, Dec. 2017, https://doi.org/10.1016/j.hpe.2016.12.002.
G. E. Miller, “The assessment of clinical skills/competence/performance,” Academic Medicine, vol. 65, no. 9, pp. S63-7, Sep. 1990, https://doi.org/10.1097/00001888-199009000-00045.
N. Bodagh, J. Bloomfield, P. Birch, and W. Ricketts, “Problem-based learning: a review,” Br J Hosp Med, vol. 78, no. 11, pp. C167–C170, Nov. 2017, https://doi.org/10.12968/hmed.2017.78.11.C167.
A. Burgess et al., “Scaffolding medical student knowledge and skills: team-based learning (TBL) and case-based learning (CBL),” BMC Med Educ, vol. 21, no. 1, p. 238, Dec. 2021, https://doi.org/10.1186/s12909-021-02638-3.
F. Chen, A. M. Lui, and S. M. Martinelli, “A systematic review of the effectiveness of flipped classrooms in medical education,” Med Educ, vol. 51, no. 6, pp. 585–597, Jun. 2017, https://doi.org/10.1111/medu.13272.
D. Dolmans, L. Michaelsen, J. van Merriënboer, and C. van der Vleuten, “Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds!,” Med Teach, vol. 37, no. 4, pp. 354–359, Apr. 2015, https://doi.org/10.3109/0142159X.2014.948828.
J. C. Trullàs, C. Blay, E. Sarri, and R. Pujol, “Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review,” BMC Med Educ, vol. 22, no. 1, p. 104, Dec. 2022, https://doi.org/10.1186/s12909-022-03154-8.
N. R. Wijesooriya, V. Mishra, P. L. P. Brand, and B. K. Rubin, “COVID-19 and telehealth, education, and research adaptations,” Paediatr Respir Rev, vol. 35, pp. 38–42, Sep. 2020, https://doi.org/10.1016/j.prrv.2020.06.009.
R. Hilburg, N. Patel, S. Ambruso, M. A. Biewald, and S. S. Farouk, “Medical Education During the Coronavirus Disease-2019 Pandemic: Learning From a Distance,” Adv Chronic Kidney Dis, vol. 27, no. 5, pp. 412–417, Sep. 2020, https://doi.org/10.1053/j.ackd.2020.05.017.
R. Hilburg, N. Patel, S. Ambruso, M. A. Biewald, and S. S. Farouk, “Medical Education During the Coronavirus Disease-2019 Pandemic: Learning From fromstance,” Adv Chronic Kidney Dis, vol. 27, no. 5, pp. 412–417, Sep. 2020, https://doi.org/10.1053/j.ackd.2020.05.017.
N. Nimavat et al., “Online Medical Education in India – Different Challenges and Probable Solutions in the Age of COVID-19,” Adv Med Educ Pract, vol. Volume 12, pp. 237–243, Mar. 2021, https://doi.org/10.2147/AMEP.S295728.
S. Rose, “Medical Student Education in the Time of COVID-19,” JAMA, vol. 323, no. 21, p. 2131, Jun. 2020, https://doi.org/10.1001/jama.2020.5227.
P. J. Slanetz, U. Parikh, T. Chapman, and C. L. Motuzas, “Coronavirus Disease 2019 (COVID-19) and Radiology Education—Strategies for Sur-vival,” Journal of the American College of Radiology, vol. 17, no. 6, pp. 743–745, Jun. 2020, https://doi.org/10.1016/j.jacr.2020.03.034.
P. A. Kotta, M. Elango, N. Matcha, and K. Y. Chow, “Foundation doctors’ perspectives on the impact of the COVID-19 pandemic and lessons for the future.,” Clin Med (Lond), vol. 21, no. 5, pp. e522–e525, Sep. 2021, https://doi.org/10.7861/clinmed.2021-0244.
S. J. Halperin, J. R. Zhu, J. S. Francis, and J. N. Grauer, “Are Medical School Curricula Adapting with Their Students? A Survey on How Medical Students Study and How it Relates to USMLE Step 1 Scores,” J Med Educ Curric Dev, vol. 11, 2024, https://doi.org/10.1177/23821205241228455.
A. A. Kononowicz, N. Zary, S. Edelbring, J. Corral, and I. Hege, “Virtual patients - what are we talking about? A framework to classify the mean-ings of the term in healthcare education,” BMC Med Educ, vol. 15, no. 1, p. 11, Dec. 2015, https://doi.org/10.1186/s12909-015-0296-3.
H. Ahmed, M. Allaf, and H. Elghazaly, “COVID-19 and medical education,” Lancet Infect Dis, vol. 20, no. 7, pp. 777–778, Jul. 2020, https://doi.org/10.1016/S1473-3099(20)30226-7.
F. Jones, C. Passos-Neto, and O. Melro Braghiroli, “Simulation in Medical Education: Brief history and methodology,” Principles and Practice of Clinical Research Journal, vol. 1, no. 2, pp. 56–63, Sep. 2015, https://doi.org/10.21801/ppcrj.2015.12.8.
J. O. Lopreiato and T. Sawyer, “Simulation-Based Medical Education in Pediatrics,” Acad Pediatr, vol. 15, no. 2, pp. 134–142, Mar. 2015, https://doi.org/10.1016/j.acap.2014.10.010.
G. Makransky et al., “Simulation based virtual learning environment in medical genetics counseling: an example of bridging the gap between theory and practice in medical education,” BMC Med Educ, vol. 16, no. 1, p. 98, Dec. 2016, https://doi.org/10.1186/s12909-016-0620-6.
J. Moran, G. Briscoe, and S. Peglow, “Current Technology in Advancing Medical Education: Perspectives for Learning and Providing Care,” Aca-demic Psychiatry, vol. 42, no. 6, pp. 796–799, Dec. 2018, https://doi.org/10.1007/s40596-018-0946-y.
C. Pinter et al., “SlicerVR for Medical Intervention Training and Planning in Immersive Virtual Reality,” IEEE Trans Med Robot Bionics, vol. 2, no. 2, pp. 108–117, May 2020, https://doi.org/10.1109/TMRB.2020.2983199.
W. Song et al., “An Intelligent Virtual Standard Patient for Medical Students Training Based on Oral Knowledge Graph,” IEEE Trans Multimedia, vol. 25, pp. 6132–6145, 2023, https://doi.org/10.1109/TMM.2022.3205456.
S. Tabatabai, “Simulations and Virtual Learning Supporting Clinical Education During the COVID 19 Pandemic,” Adv Med Educ Pract, vol. Vol-ume 11, pp. 513–516, Aug. 2020, https://doi.org/10.2147/AMEP.S257750.
R.-J. Wilcha, “Effectiveness of Virtual Medical Teaching During the COVID-19 Crisis: Systematic Review,” JMIR Med Educ, vol. 6, no. 2, p. e20963, Nov. 2020, https://doi.org/10.2196/20963.
N. K. Dicheva, I. U. Rehman, A. Anwar, M. M. Nasralla, L. Husamaldin, and S. Aleshaiker, “Digital Transformation in Nursing Education: A Sys-tematic Review on Computer-Aided Nursing Education Pedagogies, Recent Advancements and Outlook on the Post-COVID-19 Era,” IEEE Ac-cess, vol. 11, pp. 135659–135695, 2023, https://doi.org/10.1109/ACCESS.2023.3337669.
R. H. Ellawa, “Virtual patients as activities: exploring the research implications of an activity theoretical stance,” Perspect Med Educ, vol. 3, no. 4, pp. 266–277, Aug. 2014, https://doi.org/10.1007/S40037-014-0134-Z.
A. Kleinsmith, D. Rivera-Gutierrez, G. Finney, J. Cendan, and B. Lok, “Understanding empathy training with virtual patients,” Comput Human Behav, vol. 52, pp. 151–158, Nov. 2015, https://doi.org/10.1016/j.chb.2015.05.033.
A. Hirumi et al., “Advancing virtual patient simulations through design research and interPLAY: part I: design and development,” Educational Technology Research and Development, vol. 64, no. 4, pp. 763–785, Aug. 2016, https://doi.org/10.1007/s11423-016-9429-6.
S. Krishnamurthy, “The future of business education: A commentary in the shadow of the Covid-19 pandemic,” J Bus Res, vol. 117, pp. 1–5, 2020, https://doi.org/10.1016/j.jbusres.2020.05.034.
K. Krishnamurthy et al., “Benefits of gamification in medical education,” Clinical Anatomy, vol. 35, no. 6, pp. 795–807, Sep. 2022, https://doi.org/10.1002/ca.23916.
J. Lee, H. Kim, K. H. Kim, D. Jung, T. Jowsey, and C. S. Webster, “Effective virtual patient simulators for medical communication training: A sys-tematic review,” Med Educ, vol. 54, no. 9, pp. 786–795, Sep. 2020, https://doi.org/10.1111/medu.14152.
J. Pottle, “Virtual reality and the transformation of medical education,” Future Healthc J, vol. 6, no. 3, pp. 181–185, Oct. 2019, https://doi.org/10.7861/fhj.2019-0036.
F. L. Ricci, F. Consorti, F. Pecoraro, D. Luzi, and O. Tamburis, “A Petri-Net-Based Approach for Enhancing Clinical Reasoning in Medical Educa-tion,” IEEE Transactions on Learning Technologies, vol. 15, no. 2, pp. 167–178, Apr. 2022, https://doi.org/10.1109/TLT.2022.3157391.
S. Sai, A. Gaur, R. Sai, V. Chamola, M. Guizani, and J. J. P. C. Rodrigues, “Generative AI for Transformative Healthcare: A Comprehensive Study of Emerging Models, Applications, Case Studies, and Limitations,” IEEE Access, vol. 12, pp. 31078–31106, 2024, https://doi.org/10.1109/ACCESS.2024.3367715.
T. Dale MacLaine, N. Lowe, and J. Dale, “The use of simulation in medical student education on the topic of breaking bad news: A systematic re-view,” Patient Educ Couns, vol. 104, no. 11, pp. 2670–2681, Nov. 2021, https://doi.org/10.1016/j.pec.2021.04.004.
P. and P. F. C. M. C. Donald Combs, “Emerging Roles of Virtual Patients in the Age of AI,” AMA J Ethics, vol. 21, no. 2, pp. E153-159, Feb. 2019, https://doi.org/10.1001/amajethics.2019.153.
W. F. Bond et al., “Virtual Standardized Patient Simulation,” Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, vol. 14, no. 4, pp. 241–250, Aug. 2019, https://doi.org/10.1097/SIH.0000000000000373.
S. I. , S. J. M. and S. I. M. Saniya Raghib Sabzwari1, “Creation of Virtual Patients for Undergraduate and Postgraduate Medical Education: An Experience from Pakistan,” Journal of the College of Physicians and Surgeons Pakistan, vol. 33, no. 04, pp. 457–459, Apr. 2023, https://doi.org/10.29271/jcpsp.2023.04.457.
C. Tay, A. Khajuria, and C. Gupte, “Simulation training: A systematic review of simulation in arthroscopy and proposal of a new competency-based training framework,” International Journal of Surgery, vol. 12, no. 6, pp. 626–633, Jun. 2014, https://doi.org/10.1016/j.ijsu.2014.04.005.
I. Hege, A. A. Kononowicz, D. Tolks, S. Edelbring, and K. Kuehlmeyer, “A qualitative analysis of virtual patient descriptions in healthcare educa-tion based on a systematic literature review,” BMC Med Educ, vol. 16, no. 1, p. 146, Dec. 2016, https://doi.org/10.1186/s12909-016-0655-8.
Al-Harbi, R. (2023). AI-driven virtual patient simulations in medical training: A GCC perspective. Journal of Medical Simulation, 12(4), 211–225.
Zhang, L., & Kim, S. (2024). Integrating VR and AI in clinical education: A systematic review. Computers in Education, 179, 104653.